What is the next best step in managing bleeding from a stoma?

Management of Stomal Bleeding

The next best step in managing stomal bleeding is to assess hemodynamic stability and check vital signs, hemoglobin/hematocrit, and coagulation parameters, followed by direct visual inspection of the uncovered stoma to differentiate between simple mucosal bleeding and parastomal varices, which fundamentally determines the treatment pathway. 1

Initial Assessment and Stabilization

Hemodynamic Evaluation

• Check vital signs immediately and calculate the shock index (heart rate/systolic BP); a shock index >1 indicates hemodynamic instability requiring urgent intervention 1
• Obtain hemoglobin, hematocrit, and coagulation studies to assess bleeding severity 1
• For severe bleeding, perform blood typing and cross-matching 1
• In clinically stable patients requiring transfusion, use restrictive thresholds: Hb trigger of 70 g/L (target 70-90 g/L), or 80 g/L trigger (target 100 g/L) if cardiovascular disease is present 1

Critical Diagnostic Step: Stoma Examination

• Remove the ostomy appliance and directly inspect the stoma - this is essential as failing to examine the uncovered ostomy is a common pitfall that delays diagnosis of parastomal varices 2
• Look for specific features that distinguish variceal from non-variceal bleeding:
  • Parastomal varices: raspberry appearance, visibly dilated submucosal veins, bluish discoloration and hyperkeratosis of peristomal skin, though these pathognomonic signs are present in only a minority of cases 3
  • Simple mucosal bleeding: focal bleeding points, trauma from appliance changes, or diffuse mucosal oozing without venous engorgement

Management Algorithm Based on Bleeding Source

For Non-Variceal Stomal Bleeding (Simple Mucosal Trauma)

• Apply direct manual compression as first-line therapy 4, 2
• Address mechanical causes: ensure proper appliance fit (cut opening one-eighth inch larger than stoma), use convex appliances, ostomy belts, paste, or barrier rings to prevent leakage and trauma 1
• Thicken stool with antidiarrheals if liquid effluent is contributing to irritation 1
• If bleeding persists despite local measures, consider flexible endoscopy through the stoma to identify and treat specific bleeding points 1

For Parastomal Variceal Bleeding

Hemodynamically Stable Patients

• Doppler ultrasound or venous phase contrast angiography/portal venography to confirm diagnosis - these are the most successful radiological investigations 3, 2
• Manual compression by the patient can control focal variceal bleeding temporarily, particularly when bleeding originates from a specific mesenteric varix rather than diffuse congestion 4
• Avoid local surgical measures (suture ligation, stoma revision) as first-line definitive therapy - these have the highest rebleeding rates (approximately 50-75% will rebleed) 5, 3, 2

Hemodynamically Unstable Patients

• CT angiography (CTA) provides the fastest, least invasive means to localize active bleeding 1
• If CTA is positive and interventional radiology is available, proceed directly to catheter angiography with embolization within 60 minutes 1

Definitive Management Options for Parastomal Varices (in order of effectiveness):

1. Transjugular Intrahepatic Portosystemic Shunt (TIPS) - highest success rate for preventing recurrent hemorrhage:

   • Reduces rebleeding risk by 78.5% 3
   • Number needed to treat: 1.37 patients to prevent one rebleeding episode 3
   • Particularly effective for diffusely congested stomas with diffuse venous oozing 4
   • Should be considered first-line definitive therapy when portal or mesenteric veins are patent 4

2. Transvenous obliteration/embolization for focal variceal bleeding:

   • Direct percutaneous approach with ultrasound-guided compression is least invasive 4, 6
   • Use 1% sodium tetradecyl sulfate (not 3%) for sclerotherapy 4
   • Options include balloon-occluded retrograde transvenous obliteration (BRTO), percutaneous transhepatic obliteration, or trans-TIPS balloon-occluded antegrade transvenous obliteration 4
   • Effective as bridge therapy in decompensated patients awaiting shunt procedures or liver transplantation 6
   • Approximately 50% rebleeding rate when used alone 3

3. Surgical portosystemic shunting - approximately 50% rebleeding rate 3

4. Liver transplantation - addresses underlying portal hypertension but rarely used solely for parastomal varices 3, 2

5. Local measures (sclerotherapy, stoma revision) - least effective with highest rebleeding rates:

   • Sclerotherapy causes unacceptable stomal damage 2
   • Stoma revision has high recurrence risk (rebleeding within 1 month documented) 5
   • Should be used only as temporary measures 5, 2

Special Considerations

Portal Hypertension Context

• Approximately one-third of patients with parastomal varices have coexistent esophageal varices 3
• Multidisciplinary management with early hepatology involvement is essential 1
• Consider vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow and portal pressure 1
• Non-selective beta-blockers for prophylaxis, but temporarily suspend during acute bleeding 1

Common Pitfalls to Avoid

• Do not proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 1
• Do not rely on stoma revision as definitive therapy for variceal bleeding - it is a temporizing measure at best 5, 3
• Do not perform sclerotherapy for parastomal varices due to risk of stomal damage 2
• Recognition of stomal varices is typically delayed when failing to examine the ostomy without the appliance 2

Risk Factors for Parastomal Varices

• More frequent in men, typically manifesting in the fifth decade 3
• 72% occur from ileostomies rather than colostomies 3
• Most common underlying pathology: ulcerative colitis (57.8%) 3
• Liver cirrhosis is the most common cause of portal hypertension, followed by primary sclerosing cholangitis 3